DCW98-Intermediate Care and Reablement Support Policy
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Intermediate Care and Reablement Support Policy
1. Purpose
The purpose of this policy is to ensure that {{org_field_name}} provides high-quality, person-centred intermediate care and reablement support to individuals recovering from illness, surgery, or hospital discharge. The policy aims to facilitate independence, functional recovery, and improved quality of life, reducing the need for long-term care or hospital readmission.
Our objectives are to:
- Enable individuals to regain skills and confidence in daily living activities.
- Promote independence, preventing unnecessary hospitalisation or long-term care dependency.
- Support individuals in transitioning from hospital to home safely.
- Provide a structured, time-limited reablement programme tailored to service users’ needs.
- Ensure a multi-disciplinary approach, working with health and social care professionals.
- Meet Care Inspectorate Wales (CIW) regulations and national standards for reablement care.
2. Scope
This policy applies to:
- Service users receiving intermediate care and reablement support.
- All employees, including reablement care workers, supervisors, and managers.
- The Registered Manager and Responsible Individual, ensuring compliance and oversight.
- Healthcare professionals, including physiotherapists, occupational therapists, and GPs.
- Families and carers, who support service users in regaining independence.
- Local authorities and social services, involved in intermediate care planning.
3. Legal and Regulatory Framework
This policy aligns with:
- The Regulation and Inspection of Social Care (Wales) Act 2016, ensuring safe, high-quality reablement services.
- The Social Services and Well-being (Wales) Act 2014, promoting independence and recovery.
- NICE Guidelines on Intermediate Care and Reablement, ensuring best practices.
- The Health and Safety at Work Act 1974, safeguarding staff and service users.
- Care Inspectorate Wales (CIW) Quality Standards, ensuring high-quality care delivery.
- The Mental Capacity Act 2005, ensuring individuals are supported to make informed decisions.
- The Equality Act 2010, ensuring fair access to reablement support.
4. Defining Intermediate Care and Reablement
4.1 What is Intermediate Care?
Intermediate care is a short-term, targeted intervention designed to:
- Support hospital discharge and prevent unnecessary admissions.
- Facilitate recovery from illness, surgery, or injury.
- Help individuals regain independence in daily living activities.
4.2 What is Reablement Support?
Reablement focuses on:
- Restoring functional ability, such as mobility, cooking, and personal care.
- Encouraging service users to develop self-care skills.
- Reducing reliance on long-term care services.
How we manage this efficiently:
- Each service user has an individualised reablement plan.
- Care staff are trained in promoting independence, rather than doing tasks for the individual.
- Regular progress assessments ensure timely goal adjustments.
5. Eligibility and Assessment for Reablement Support
5.1 Identifying Suitable Service Users
Intermediate care and reablement are suitable for individuals who:
- Have been recently discharged from hospital and require temporary support.
- Are recovering from illness, injury, or surgery.
- Need assistance regaining mobility, self-care, or daily living skills.
- Would benefit from short-term interventions to prevent deterioration.
5.2 Initial Assessment and Goal Setting
Each service user will receive:
- A comprehensive assessment by a multi-disciplinary team, including social workers, physiotherapists, and occupational therapists.
- A personalised care and reablement plan, setting specific, measurable goals.
- Risk assessments, ensuring safety in the home environment.
How we manage this efficiently:
- Collaboration with hospital discharge teams to ensure smooth transitions.
- Regular case reviews to monitor progress and adjust care plans accordingly.
6. Developing Personalised Reablement Plans
Each service user’s reablement plan includes:
- Clearly defined independence goals (e.g., dressing, cooking, walking).
- Strategies for regaining skills and adapting to limitations.
- Support for medication management and nutrition.
- Psychological and emotional support to boost confidence.
How we manage this efficiently:
- Plans are developed in collaboration with the service user and healthcare professionals.
- A key worker is assigned to oversee each individual’s progress.
7. Delivering Reablement Support
7.1 Encouraging Independence
Care workers will:
- Support, rather than do tasks for the service user.
- Use verbal cues and prompts to encourage self-care.
- Implement adaptive techniques and assistive devices where needed.
7.2 Promoting Physical Recovery and Well-being
- Support physiotherapy-led exercises to regain strength and mobility.
- Encourage healthy nutrition to aid recovery.
- Monitor and manage medication adherence.
How we manage this efficiently:
- Staff receive specialised reablement training.
- Regular progress meetings ensure adjustments to support strategies.
8. Monitoring Progress and Adjusting Support
8.1 Weekly Progress Reviews
- Regular evaluations track service users’ progress against their goals.
- Adjustments are made if additional support is required.
8.2 When to Transition to Long-Term Care
- If reablement goals are met, the service user is discharged from the programme.
- If further support is needed, referrals are made to long-term care providers.
How we manage this efficiently:
- Data-driven decision-making ensures service users receive the right level of care.
- Care teams work closely with social workers to determine next steps.
9. Preventing Hospital Readmission
9.1 Identifying Early Signs of Deterioration
- Regular health checks monitor signs of relapse.
- Care staff report concerns to healthcare professionals promptly.
9.2 Crisis Prevention Planning
- Emergency care plans are in place for high-risk individuals.
- Proactive medication management prevents avoidable complications.
How we manage this efficiently:
- Emergency response procedures are built into reablement plans.
- Rapid response teams ensure quick intervention when needed.
10. Staff Training and Competency in Reablement Care
10.1 Mandatory Training Includes:
- Techniques to promote independence and self-care.
- Mobility support and falls prevention.
- Psychosocial approaches to building confidence.
- Infection control and medication management.
10.2 Competency Assessments
- Care workers must demonstrate practical skills in reablement techniques.
- Annual refresher training ensures up-to-date knowledge.
How we manage this efficiently:
- A reablement lead oversees staff training and competency checks.
- Peer coaching supports continuous learning and development.
11. Multi-Agency Collaboration and Communication
- Work in partnership with physiotherapists, occupational therapists, and district nurses.
- Ensure open communication with GPs and hospital discharge teams.
- Regular care coordination meetings review service user progress.
How we manage this efficiently:
- Digital care records enable seamless information sharing.
- Regular case discussions enhance multi-agency collaboration.
12. Related Policies
This policy aligns with:
- Hospital Discharge and Transition to Home Care Policy (DCW26).
- Falls Prevention and Mobility Support Policy (DCW37).
- Medication Management Policy (DCW21).
- Safeguarding Adults Policy (DCW13).
13. Policy Review
This policy will be reviewed annually or sooner if required due to legislative changes, business needs, or CIW updates. The Registered Manager and Responsible Individual are responsible for ensuring compliance.
Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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